Would a Sodium-Glucose Cotransporter 2 (SGLT2) inhibitor be the next appropriate treatment step for a 70-year-old patient with Type 2 diabetes mellitus (T2DM), well-managed blood pressure, an Hemoglobin A1C (HbA1C) level of 7, and impaired renal function indicated by a urinary Albumin-to-Creatinine Ratio (ACR) of approximately 60?

SGLT2 Inhibitor is Strongly Recommended as Your Next Step

Yes, initiate an SGLT2 inhibitor immediately for this patient—this is a Grade 1A recommendation based on the most recent KDIGO 2022 guidelines, prioritizing renal protection over glycemic control alone. 1

Why SGLT2i is the Clear Choice Here

Your patient has albuminuria (ACR ~60 mg/g, which equals ~600 mg/mmol in Canadian units), well-controlled A1C, and well-managed blood pressure. This clinical picture screams for renal protection, not just glucose lowering. The KDIGO 2022 guidelines explicitly recommend treating patients with T2D, CKD, and eGFR ≥30 mL/min/1.73 m² with an SGLT2 inhibitor as a Grade 1A recommendation—the highest level of evidence. 1

The Evidence is Overwhelming

• SGLT2 inhibitors reduce albuminuria by 32-41% in patients with microalbuminuria (30-300 mg/g), and this effect is largely independent of improvements in A1C, blood pressure, or weight. 2
• The DAPA-CKD trial demonstrated a 39% reduction in the composite outcome of sustained eGFR decline ≥50%, end-stage kidney disease, or renal/cardiovascular death (HR 0.61,95% CI 0.51-0.72). 3
• The renal-specific composite outcome was reduced by 44% (HR 0.56,95% CI 0.45-0.68), and cardiovascular death or heart failure hospitalization was reduced by 29% (HR 0.71,95% CI 0.55-0.92). 3

Practical Implementation Algorithm

Step 1: Choose Your SGLT2 Inhibitor

Prioritize agents with documented kidney or cardiovascular benefits: 1

• Dapagliflozin 10 mg once daily (preferred for CKD with albuminuria ≥30 mg/g and eGFR ≥25 mL/min/1.73 m²) 3
• Empagliflozin 10-25 mg once daily (proven cardiovascular benefits, can be used if eGFR ≥45 mL/min/1.73 m²) 1
• Canagliflozin 100 mg once daily (FDA-approved to reduce CV death in T2D with CV disease; use 100 mg if eGFR 45-59 mL/min/1.73 m²) 1

Step 2: Pre-Initiation Assessment

Before starting the SGLT2i: 1, 3

• Check eGFR and volume status—if the patient is on diuretics or has tenuous volume status, consider reducing diuretic doses first
• Review current medications—if on insulin or sulfonylureas, you may need to reduce doses to prevent hypoglycemia (though with A1C at 7, this is less of a concern)
• Educate the patient about genital mycotic infections (~6% risk), volume depletion symptoms, and the importance of withholding the drug during acute illness (sick day rules)

Step 3: Add SGLT2i to Current Regimen

You can simply add the SGLT2i to metformin (or whatever the patient is currently on) without stopping anything. 1

• The KDIGO guidelines explicitly state that an SGLT2i can be added to other antihyperglycemic medications when glycemic targets are met but the patient can benefit from additional renal/cardiovascular protection. 1
• Since the A1C is already at 7%, you're adding this primarily for renal and cardiovascular protection, not glucose lowering. 1

Step 4: Anticipate and Manage the Initial eGFR Dip

Expect a reversible 3-5 mL/min/1.73 m² drop in eGFR within the first 1-4 weeks—this is hemodynamic, not harmful, and is NOT a reason to stop the drug. 1, 3

• Recheck eGFR within 1-2 weeks after initiation 3
• If eGFR drops >30% from baseline AND there are signs of hypovolemia, reduce diuretic doses first before considering stopping the SGLT2i 3
• Continue the SGLT2i even if eGFR falls below 30 mL/min/1.73 m² or even below 20 mL/min/1.73 m², as long as it's tolerated and kidney replacement therapy is not imminent 1, 3

Step 5: Ongoing Monitoring

• Recheck eGFR and ACR at 3-6 months to assess response 1
• Monitor for genital mycotic infections (counsel on daily hygiene) 3, 4
• Educate on sick day rules: withhold SGLT2i during acute illness with reduced oral intake, fever, vomiting, or diarrhea to prevent diabetic ketoacidosis 3, 5

Common Pitfalls to Avoid

Pitfall #1: Stopping the Drug When eGFR Dips

Do NOT discontinue the SGLT2i solely because eGFR falls below 45 mL/min/1.73 m² or even below 30 mL/min/1.73 m². The cardiovascular and renal protective benefits persist even when glycemic efficacy is lost. 1, 3

Pitfall #2: Waiting for A1C to Rise Before Adding SGLT2i

This patient's A1C is already at goal (7%), but that's irrelevant. The indication here is albuminuria and renal protection, not glucose lowering. The KDIGO guidelines explicitly state that an SGLT2i can be added when glycemic targets are met but the patient can safely benefit from additional protection. 1

Pitfall #3: Ignoring Sick Day Rules

Euglycemic diabetic ketoacidosis (DKA) can occur even with normal blood glucose levels. Educate the patient to withhold the SGLT2i during acute illness, prolonged fasting, or surgery. 3, 5

Pitfall #4: Not Educating About Genital Mycotic Infections

Genital mycotic infections occur in ~6% of patients on SGLT2 inhibitors vs. 1% on placebo. Counsel on daily hygiene and prompt treatment if symptoms develop. 3, 4

Why Not Wait for GLP-1 RA?

While GLP-1 receptor agonists also have cardiovascular and renal benefits, SGLT2 inhibitors have stronger evidence for slowing CKD progression in patients with albuminuria. 1, 4 The KDIGO 2022 guidelines give SGLT2 inhibitors a Grade 1A recommendation for patients with T2D, CKD, and eGFR ≥30 mL/min/1.73 m², whereas GLP-1 RAs are recommended when glycemic targets are not met despite metformin and SGLT2i. 1

Bottom line: Start the SGLT2i now. This is the single most impactful intervention you can make to slow this patient's kidney disease progression and reduce cardiovascular risk. 1, 4